Does a facelift approach change when the face contains illicit filler?
Appropriate treatment and surgical techniques, recovery, and outcomes may vary.
A specific diagnosis and surgical plan must be determined through medical examination and consultation.
In brief, assessment and planning may differ from those for a standard facelift
So-called 'illicit filler' or injected material of unknown composition remaining in the face does not necessarily rule out a facelift.
However, more factors may require assessment before surgery than in a face without injected material.
The extent of dissection, method of tissue fixation, and need to remove foreign material may vary according to the location and extent of the material, surrounding inflammation and fibrosis, and condition of the skin and subcutaneous tissue.
In particular, if injected material has spread beyond the subcutaneous tissue to the SMAS layer or around muscles,
or normal tissue has hardened through a foreign-body reaction, normal anatomical planes may become indistinct.
Planning must therefore consider the foreign material and surrounding tissue changes together, rather than approaching surgery simply as pulling sagging skin.
What exactly does 'illicit filler' mean?
'Illicit filler' is not a medical diagnosis denoting one specific ingredient.
The term generally refers to unapproved injected substances, products with an unverified distribution channel or treatment process, or cosmetic injections performed outside a medical facility.
However, a patient's inability to remember the product used long ago does not establish that the treatment was unlawful.
Injected material of unknown composition because records are unavailable or the product name is forgotten should be distinguished from genuinely unapproved substances.
Potentially problematic injected materials include liquid silicone or paraffin used for cosmetic purposes, industrial substances, and mixtures of unidentifiable composition.
Meanwhile, the regulatory status of nonabsorbable fillers such as PMMA may differ according to country, product, and approved treatment site.
An ingredient name alone therefore does not establish legality; the actual product, injection setting, and approved indications must also be checked.
Under U.S. FDA criteria, liquid silicone is not approved for cosmetic injection into the face or body, and reported risks include persistent pain, infection, scarring, tissue necrosis, and permanent disfigurement.
The FDA also explains that permanent fillers and injected substances other than hyaluronic acid may be difficult or impossible to remove completely.
Why can illicit filler complicate a facelift?
A facelift involves more than removing and tightening skin.
It requires identifying facial anatomy, including subcutaneous tissue, the SMAS layer, and retaining ligaments, dissecting in an appropriate tissue plane, and repositioning and securing sagging tissue.
If material of unknown composition or nonabsorbable material has spread through facial tissue, the following changes may occur.
- Chronic inflammation or foreign-body granulomas may form around the material.
- Fibrosis and adhesions may develop, causing tissue to harden.
- The boundary between normal tissue and foreign material may be indistinct.
- Injected material may migrate from the original treatment site.
- Nodules, swelling, skin discoloration, or asymmetry may develop.
- Repeated inflammation or previous removal surgery may leave uneven skin and subcutaneous tissue thickness.
- Infection or inflammation may thin the skin or cause wounds.
These changes may make standard facelift dissection planes unsuitable. Normal tissue, foreign material, and fibrotic tissue must be distinguished during surgery, allowing for normal anatomical planes that may have been obscured by adhesions.
Recurrent inflammation, extensive fibrosis, or previous removal surgery may require particularly careful adjustment of dissection direction and extent to preserve skin and normal tissue.
What should be assessed before surgery?
First, establish when, where, what material, and how many times it was injected. Available product names and previous medical records are helpful at consultation.
Even if the product name is unknown, provide the following information as specifically as possible.
- When injections began and the number of treatments
- The facial areas injected
- When swelling or inflammation first developed after treatment
- Any firm nodules, pain, warmth, or skin color changes
- Any history of open wounds or discharge
- Previous foreign-material removal surgery or incisional treatment
- Previous antibiotic or injection treatment
Examination assesses the extent of palpable foreign material, skin thickness, tissue firmness, degree of adhesion, asymmetry, nodules, and signs of inflammation.
If needed, high-frequency ultrasound or MRI may help assess the location and distribution of deposited material and associated abnormalities such as nodules or abscesses.
However, imaging and clinical findings do not always agree about migration or the actual extent of inflammation.
Even when a material produces characteristic imaging findings, imaging alone cannot establish its exact composition or perfectly predict adhesions and the actual difficulty of surgical dissection.
Imaging should therefore support assessment alongside examination and treatment history, rather than independently determine the surgical approach.
Can a facelift be performed immediately when inflammation is present?
Inflammation does not rule out all surgery, but suspected active infection requires assessment of inflammation and infection before proceeding directly with an elective cosmetic facelift.
The following symptoms warrant priority assessment for infection or active inflammation.
- Suddenly worsening redness and warmth
- Continuously increasing pain and swelling
- A firm nodule that becomes painful or rapidly enlarges
- A skin wound or pus-like discharge
- Associated fever or flu-like symptoms
Depending on the cause and extent of inflammation, medication, drainage, biopsy, or foreign-material removal may be performed first.
A facelift may be planned after inflammation is controlled, or foreign-material removal and tissue reconstruction may be considered together depending on the condition.
Does illicit filler change the method of facelift dissection?
It may. However, illicit filler or permanent injected material does not necessarily require one particular facelift technique.
The surgical approach is determined by considering the following factors together.
- Whether foreign material is mainly in the subcutaneous layer
- Whether it extends into the SMAS layer or deeper
- The severity of fibrosis and adhesions
- Whether granulomas or nodules require removal
- How much normal skin and fat can be preserved
- Whether tissue defects or contour depressions are expected after removal
- The locations of facial sagging and asymmetry
If normal dissection planes are relatively well preserved, they may be used for the facelift.
Extensive adhesions or granulomas, however, may require adjustment of the direction and extent of dissection to reduce normal tissue damage.
The priority is not indiscriminate extensive removal or deep dissection. Symptomatic tissue and facial sagging need to be addressed while preserving as much normal fat, muscle, and skin as possible.
Can foreign-material removal and a facelift be performed together?
They may be performed together depending on the patient's condition.
Repositioning loose tissue after removing foreign material and granulomas may help address protrusion or asymmetry caused by the material together with facial sagging.
In some cases, tissue defects or loose skin remaining after foreign-material removal need to be addressed during the facelift.
One retrospective study of 50 patients undergoing permanent filler removal and facelift used a short-scar facelift with SMAS suturing.
The study reported a statistically significant difference in preoperative versus postoperative asymmetry assessments, with 62% of all patients satisfied with the outcome.
However, this was a single retrospective study with a limited patient population and surgical technique, so the findings cannot be applied equally to all patients.
The findings alone also do not establish that all patients with permanent filler can undergo combined removal and facelift or expect a similar outcome.
Staged treatment, with removal and facelift performed separately, may be considered in the following situations.
- Active infection or severe inflammation
- Thinned or damaged skin
- Material spread extensively across multiple tissue layers
- An anticipated large tissue defect after removal
- A particular need to preserve skin and normal tissue
- A need to observe tissue changes after initial removal
The choice between combined and staged surgery is not determined by the type of foreign material alone.
Inflammation, skin and subcutaneous tissue damage, the extent of required removal, anticipated defects, and facelift extent must be considered together.
Can illicit filler be completely removed surgically?
Complete removal of all foreign material is not always possible.
If the injected material is confirmed or strongly suspected to be hyaluronic acid filler, dissolution with hyaluronidase may be considered depending on the condition.
Hyaluronidase does not act on nonabsorbable substances such as liquid silicone, paraffin, or PMMA. It also cannot be applied indiscriminately to material of unknown composition.
Nonabsorbable substances may spread as tiny droplets among normal tissue or become mixed with surrounding fibrous tissue.
Attempting to remove all material in these circumstances may also damage normal fat, muscle, blood vessels, or skin.
Surgery may therefore focus on limited removal of the following areas.
- Lesions causing recurrent inflammation
- Nodules causing pain or firmness
- Granulomas distorting facial contours
- Tissue associated with skin damage or wounds
- Areas obstructing facelift dissection and tissue movement
The realistic goal of foreign-material removal is to reduce problems such as inflammation, pain, firmness, protrusion, and asymmetry while preserving as much normal tissue as possible, rather than eliminate every microscopic trace.
Some material may remain for safety. This possibility, and the possibility of later recurrent inflammation or deformity from retained material, should be thoroughly discussed before surgery.
Can a facelift be performed without removing foreign material?
Not all foreign material necessarily requires removal. However, whether a standard facelift can be performed while leaving it in place requires careful judgment.
If material is widely distributed and complete removal is expected to cause substantial normal tissue damage, limited removal of areas causing symptoms or interfering with surgery may be considered.
Conversely, foreign material and granulomas invading the facelift dissection plane or obstructing tissue movement may require some removal.
If inflammation or skin damage is present, treatment of the material and inflammation may take priority over a facelift.
No single rule of 'remove everything before lifting' or 'lift without removal' can therefore be applied to all patients.
The extent of removal and whether a facelift can be combined with it may depend on examination, imaging, and tissue conditions found during surgery.
Can swelling or firmness recur after a facelift?
The possibility of recurrent inflammation, swelling, firmness, or nodules cannot be completely excluded after surgery.
Symptoms may recur or appear elsewhere if some widely distributed foreign material remains, a chronic foreign-body reaction has already developed, or there is a history of repeated inflammation or infection.
The usual facelift risks must also be considered, including bleeding, hematoma, infection, skin necrosis, delayed wound healing, scarring, altered sensation, facial nerve injury, contour irregularities, and asymmetry.
The degree of risk varies with the material's type and extent, skin condition, inflammation, and surgical history.
Before surgery, expected improvement should therefore be discussed together with the possibility of incomplete removal, residual firmness and asymmetry, and further treatment.
Frequently asked questions
Can I have a facelift if I have illicit filler?
In some cases, yes. However, feasibility and approach must be determined after assessing the location and extent of the material, inflammation and adhesions, and any skin or subcutaneous tissue damage.
Must the foreign material be removed before a facelift?
The procedures do not always need to be separate. They may be combined depending on the patient's condition, or staged when inflammation or skin damage is severe.
Does illicit filler always require a deep-plane facelift?
No. No single technique is appropriate for every patient. The dissection plane and fixation method must be selected according to the layers involved, extent of adhesions, and condition of normal tissue.
Can ultrasound or MRI identify the injected material exactly?
Imaging may help identify its location and distribution and associated nodules or abscesses. However, imaging alone cannot always establish the exact composition or perfectly predict actual adhesions and dissection difficulty.
Can all illicit filler be removed in one operation?
Localized collections may sometimes be removed relatively distinctly, but material spread widely among normal tissue may be difficult to remove completely.
To reduce normal tissue damage, removal may be limited to symptomatic areas or treatment divided into several sessions.
A facelift may be considered even when the face contains illicit filler or injected material of unknown composition.
Compared with a standard facelift, however, the location and extent of material, inflammation and granulomas, fibrosis and adhesions, and damage to skin and subcutaneous tissue must be assessed first.
Foreign-material removal and facelift may be combined when needed, but aggressive removal of all material is not always possible or safe.
Aggressive removal of widely distributed material can also damage normal fat, muscle, and skin, causing depressions, contour irregularities, or delayed wound healing.
The goal is therefore to determine how safely inflammation, firmness, asymmetry, and facial sagging can be improved while preserving as much normal tissue as possible, rather than simply removing everything.
For questions about a facelift in a face containing illicit filler or foreign material of unknown composition, contact 02-545-3700 or 'UVOM Plastic Surgery' on KakaoTalk.